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CHAPTER 2 Linear Endobronchial Ultrasound
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7
logistic advantages. However, if EUS-B-FNA is being
considered, we recommend performing the esophageal
portion aer the bronchoscopic portion of the procedure to avoid contamination of the respiratory system.
A dedicated TBNA needle is inserted through the
working channel of the EBUS bronchoscope, and the
designated lymph node is punctured under real-time
EBUS guidance. e aspirated material can then be submitted for cytologic/pathologic diagnosis. ere is a theoretical risk for contamination of the biopsy needle or
channel as the bronchoscope is moved from one lymph
node to the next, risking over-staging. It is therefore
generally recommended that N3 nodes be biopsied rst,
then N2, then N1. Although not necessary, an on-site
cytopathologist may be able to provide immediate feedback on the quality of the biopsy specimen and potentially a preliminary diagnosis. is information may be
used to inform decisions on repeating a biopsy during
the same procedure.
COMPLICATIONS
EBUS-TBNA with linear EBUS is a safe and well-established minimally invasive modality for sampling centrally located peribronchial lesions. Complication rates
are very low, but major complications including bleeding, infection, recurrent nerve paralysis, and mortality
have been reported.
14,15
EVIDENCE
Lung Cancer
Nodal Staging in Lung Cancer
e prognosis and operability of a lung cancer patient is
inuenced by the presence of mediastinal lymph node
metastases. One meta-analysis calculated a pooled sensitivity of 0.93 (95% condence interval [CI], 0.91–0.94)
and a pooled specicity of 1.00 (95% CI, 0.99–1.00) for
detection of mediastinal nodal disease across 11 stud-
2
e sensitivity, specicity, and accuracy of EBUS-
ies.
TBNA were superior to positron emission tomography
(PET) or PET-computed tomography (PET-CT) in two
prospective trials.
and EUS-FNA has a higher staging accuracy than either
procedure alone for patients with lung cancer, with a
sensitivity of 0.86 (95% CI, 0.82–0.90) and a specicity
of 1.00 (95% CI, 0.99–1.00) in a meta-analysis covering
16,17
e combination of EBUS-TBNA
18
eight studies.
In the ASTER trial, combined staging
with upfront EBUS-TBNA plus EUS-FNA followed by
surgical staging showed higher diagnostic yield and
fewer unnecessary thoracotomies than surgical stag-
19
ing alone.
Recently published guidelines for primary
mediastinal staging in lung cancer recommend that
ultrasonography-guided needle biopsy (EBUS-TBNA
and/or EUS-FNA) be the rst-choice modality over sur-
20–22
gical staging.
However, if EBUS/EUS biopsy results
are negative, surgical staging via mediastinoscopy or
video-assisted mediastinoscopy is recommended.
Ultrasound Image Analysis of Lymph Nodes
During EBUS-TBNA, ultrasonographic features are
helpful to dierentiate malignant and benign lymph
nodes. Several features on B-mode imaging, such as size
(short axis), shape (oval vs. round), margin (indistinct
vs. distinct), echogenicity (homogeneous vs. heterogeneous), central hilar structure (CHS) (present vs. absent),
and coagulation necrosis sign (present vs. absent), have
been shown to be good predictive markers for lymph
node metastasis in non–small cell lung cancer (NSCLC).
Fujiwara et al. reported round shape, distinct margin,
heterogeneous echogenicity, and presence of coagulation necrosis sign as independent risk factors for metas-
23
Alici et al. integrated grayscale texture (anechoic,
tasis.
hypoechoic, isoechoic, or hyperechoic) with the previ-
24
ous six features to create a modied algorithm.
is
algorithm’s sensitivity, specicity, positive predictive
value (PPV), negative predictive value (NPV), and diagnostic accuracy for detecting metastatic lymph nodes
were 100%, 51.2%, 50.6%, 100%, and 67.5%, respec-
24
tively.
Doppler imaging permits assessment of blood
ow and nodal vascular patterns. Nakajima et al. classied lymph nodes by Doppler ndings: grade 0, no blood
ow or small amounts of ow; grade I, a few main vessels running toward the center of the lymph node from
the hilum; grade II, a few cuneiforms or rod-shaped ow
signals, or a few small vessels found as a long strip of
a curve; and grade III, rich ow with more than four
vessels of diering diameters and/or twist-/helical-low
25
signal.
e sensitivity, specicity, and diagnostic accuracy of this grading system (grade 0/I benign vs. grade
II/III malignant) were 87.7%, 69.6%, and 78.0%, respectively. Wang et al. classied Doppler vascular patterns
into avascular, hilar, and nonhilar (central, capsular, or
mixed); the authors combined these vascular features
with the previous six sonographic features to predict
8
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benign lymph node status.
SECTION 1 Advanced Diagnostic Bronchoscopy Procedures
26
e sensitivity, specicity,
PPV, and NPV for predicting benign lymph nodes were
81.3%, 90.9%, 85.3%, and 88.2%, respectively.
Elastography is a strain imaging technique to assess
tissue stiness, which is displayed as a color overlay
on the B-mode ultrasound image. Most systems identify hard, intermediate, and so tissues as blue, green,
27
and yellow/red, respectively.
Izumo et al. categorized
elastography image patterns into type 1 (predominantly
nonblue), type 2 (part blue, part nonblue), and type 3
(predominantly blue). e sensitivity, specicity, PPV,
NPV, and diagnostic accuracy of this classication system (type 1 benign vs. type 3 malignant) were 100.0%,
92.3%, 94.6%, 100.0%, and 96.7%, respectively. Nakajima
et al. compared nodes by sti area ratio (sti blue area
divided by total lymph node area) and found the mean
stiness ratios were signicantly greater for metastatic
lymph nodes (0.48) than benign lymph nodes (0.22,
28
P = 0.0002).
When a cut-o ratio of 0.31 was used, sen-
sitivity and specicity were 81% and 85%, respectively.
A growing area of focus is the application of articial
intelligence technologies to risk-stratify EBUS images by
malignant potential. A 2008 study by Tagoya et al. developed an articial neural network to predict the presence
of nodal metastases using linear EBUS B-mode images,
which ultimately developed a 91% diagnostic accuracy.
29
e sensitivity, specicity, and accuracy of this system
were 87.0%, 82.1%, and 85.4%, respectively. e application of articial intelligence may enable signicant
future advances in EBUS image analysis.
Restaging After Neoadjuvant Therapy
At present, the recommended treatment for stage
30
IIIA-cN2 NSCLC is chemoradiotherapy.
However,
surgical resection aer neoadjuvant chemotherapy or
chemoradiotherapy may improve the survival of patients
31,32
with stage IIIA-cN2 disease.
Accurate restaging of
the mediastinal lymph nodes in these cases is critical
to conrm mediastinal down-staging prior to consideration for surgery. Repeat mediastinoscopy may also be
considered; however, mediastinoscopy following neoadjuvant therapy can be challenging and the diagnostic yield is reduced due to development of brosis and
33–35
adhesions.
A systematic review of ve studies calculated the pooled sensitivity, specicity, and false-negative
rate of remediastinoscopy aer neoadjuvant therapy
36
as 63%, 100%, and 22%, respectively.
Transcervical
extended mediastinal lymphadenectomy has shown a
sensitivity of 96.6% for mediastinal restaging in patients
37
with NSCLC aer neoadjuvant therapy.
Mortality and
morbidity were 0.3% and 6.4%, respectively. Similarly,
restaging with EBUS-TBNA aer neoadjuvant therapy
has been reported to have lower sensitivity compared
with EBUS-TBNA used during initial lung cancer stag-
38,39
ing.
A systematic review and meta-analysis including 10 studies found that endosonographic-guided
needle biopsy (EBUS-TBNA, EUS-FNA, or combined
endoscopic and endobronchial ultrasound [CUS]) for
mediastinal restaging has a pooled sensitivity of 67%
(95% CI, 56–77) and pooled specicity of 99% (95%
40
CI, 89–100).
e discrepancy of diagnostic yields
between initial staging and restaging may relate to difculty obtaining adequate samples from down-staged
nodes, which may be smaller, brotic, and/or necrotic
following neoadjuvant therapy. ere is also diculty
dierentiating the sonographic appearance of metastases from postinammatory adhesions and degenerative
changes. Combined EBUS-TBNA and EUS-FNA could
enable more accurate minimally invasive mediastinal
restaging. Current guidelines recommend EBUS-TBNA
and/or EUS-FNA for mediastinal restaging aer neoadjuvant therapy, avoiding remediastinoscopy.
21,22
Molecular Testing Using EBUS-TBNA Samples
As the treatment of advanced NSCLC has shied toward
molecular targeted therapy, biomarker testing has
become necessary for determining the optimal treatment
of patients newly diagnosed with NSCLC. Sensitizing
mutations in the EGFR gene were rst described in 2004,
serving as the rst class of molecular targeted therapy.
41
Since then, anaplastic lymphoma kinase (ALK) gene
42
fusion,
tions
ROS1 gene rearrangements,
44
were identied as potential treatment targets.
43
and BRAF muta-
Combination therapies, including cytotoxic chemotherapy and targeted gene therapy, have improved overall
response rates, increased progression-free survival, and
may be associated with improved overall survival in
advanced NSCLC when compared with cytotoxic che-
45
motherapy alone.
e National Comprehensive Cancer
Network (NCCN) 2018 Clinical Practice Guidelines for
NSCLC recommend concomitant diagnosis, staging,
and acquisition of adequate material for molecular pro-
46
ling to improve care of patients with NSCLC.
e
importance of obtaining tissue for molecular proling
is clear. A systematic review and meta-analysis including 33 studies (2698 participants in total) found that
CHAPTER 2 Linear Endobronchial Ultrasound
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9
use of EBUS-TBNA for molecular proling of EGFR
mutation status had a pooled probability of obtaining
sucient tissue of 94.5% (95% CI, 93.2%–96.4%). For
identication of ALK mutations, the pooled probability
47
was 94.9% (95% CI, 89.4%–98.8%).
ere are several
emerging molecular targets and therapies in NSCLC,
such as PIK3CA mutation, AKT1 KRAS mutation, RET
rearrangements, MET exon 14 skipping mutations,
and activating HER2 mutations. erefore, the NCCN
2018 guidelines recommend testing using broad-based
genomic sequencing, such as next-generation sequencing (NGS). A study including 54 TBNA/FNA samples
showed a 50-gene assay panel was successful in 97.5%
and 100% of 22-G and 25-G samples, respectively.
A larger 1231-gene panel was successful in 91.3%
and 100% of 22-G and 25-G samples, respectively.
48
Another study including 115 samples undergoing a
large (341–469 gene) NGS-based panel found EBUSTBNA obtained sucient tissue in 86.1% of samples.
49
Rebiopsy by EBUS-TBNA for follow-up molecular proling can be performed safely aer initial treatment. In
the era of biomarker-driven management of cancer, the
ability to analyze EBUS-TBNA specimens for multiple
biomarkers is critical in selecting an optimal, personalized treatment plan for each patient.
Lymphoma
Approximately 10% of lymphomas are rst diagnosed in
the chest, oen as a mediastinal tumor. Subclassication,
which guides treatment and prognosis, is based on morphologic, phenotypic, genotypic, and molecular features.
Early diagnosis and staging are key to improving patient
survival in those diagnosed with lymphoma. When
available, EBUS-TBNA is a useful alternative approach
for the diagnosis and subclassication of intrathoracic
lymphoma compared to “gold standard” approaches of
mediastinoscopy, thoracoscopy, and/or thoracotomy.
In a systematic review and meta-analysis including 14
studies, the overall sensitivity and specicity of EBUSTBNA for diagnosis of lymphoma were 66.2% (95% CI,
55%–75.8%) and 99.3% (95% CI, 98.2%–99.7%), respec-
3
In subgroup analysis, sensitivity and specicity
tively.
of EBUS-TBNA for the initial diagnosis of lymphoma
were 67.1% (95% CI, 54.2%–77.9%) and 99.6% (95% CI,
99.1%–99.8%), respectively. EBUS-TBNA performed
slightly better for diagnosing lymphoma recurrence,
with a sensitivity of 77.8% (95% CI, 68.1%–85.2%)
and specicity of 99.5% (95% CI, 98.9%–99.8%). ese
diagnostic metrics are comparable to historical data on
using mediastinoscopy for the diagnosis of mediastinal
50
lymphoma.
For subtyping lymphoma, EBUS-TBNA
obtained sucient samples for ancillary testing (e.g.,
ow cytometry, uorescence in situ hybridization) in
3
63% of histologically positive samples.
is suggests
that EBUS-TBNA is an appropriate rst-choice modality in patients with suspected lymphoma for the diagnosis of both initial and recurrent disease.
Sarcoidosis
e diagnosis of sarcoidosis requires the following criteria be met: a compatible clinical and radiologic presentation, pathologic evidence of noncaseating granulomas,
and exclusion of other diseases with similar ndings
51
(e.g., infections, malignancy).
Conventional transbronchial biopsy (TBB) and TBNA were historically the
most common procedures for obtaining pathologic evidence of noncaseating granulomas. e diagnostic yields
of TBNA and TBNA + TBB are reported to be 62% and
52
83%, respectively.
EBUS-TBNA is particularly useful
for stage I/II sarcoidosis, for which lymphadenopathy is
a common feature. A meta-analysis including 15 studies found that EBUS-TBNA had a pooled diagnostic
53
accuracy of 79% (95% CI, 71%–86%).
of EBUS-TBNA was superior to TBNA or TBB alone.
Performance
51
However, a separate meta-analysis including 16 studies
found the diagnostic yield of combined EBUS-TBNA
+ TBB + endobronchial biopsy (EBB) was 89.7% and
more eective than EBUS-TBNA alone (82.7%) for the
54
diagnosis of sarcoidosis.
e pooled diagnostic odds
ratio for the two groups was 0.55 (95% CI, 0.39–0.78,
P = 0.0007). ese results suggest EBUS-TBNA, when
combined with TBB and/or EBB, can be an eective
minimally invasive approach for conrming the diagnosis of sarcoidosis.
Tuberculosis, Mediastinal Cysts, and Other
Malignant Diseases
Pulmonary tuberculosis is oen associated with mediastinal or hilar lymphadenopathy. e potential utility
of EBUS-TBNA for diagnosis of tuberculosis has been
previously reported.
the pooled sensitivity and specicity of EBUS-TBNA
for diagnosis of intrathoracic tuberculosis were 80%
(95% CI, 0.74–0.85) and 100% (95% CI, 0.99–1.00),
respectively.
9
55
A recent meta-analysis revealed
10
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SECTION 1 Advanced Diagnostic Bronchoscopy Procedures
A systematic review including 26 studies and 32 cases
outlined the utility of diagnostic and therapeutic transbronchial ultrasound approaches for the diagnosis of
10
mediastinal cysts.
However, four cases of postproce-
dural infection were identied aer TBNA.
Rice et al. reported a cases series of nodal staging
by EBUS-TBNA in malignant pleural mesothelioma,
including 38 EBUS-TBNA and 50 mediastinoscopy
5
e sensitivity and NPV were 28% and 49% for
cases.
mediastinoscopy versus 59% and 57% for EBUS, respectively. Czarnecka-Kujawa et al. likewise published a
case series including 48 patients with malignant pleural
mesothelioma who underwent EBUS-TBNA for nodal
56
staging.
e sensitivity, specicity, PPV, NPV, and diag-
nostic accuracy were 16.7%, 100%, 100%, 68.8%, and
70.6%, respectively. Although there is no large cohort
study investigating the performance of EBUS-TBNA for
the diagnosis of sarcoma, several authors have described
successful tissue acquisition in small case series.
4,57,58
EBUS Needles
Several EBUS needles are currently available across a
range of sizes (25-, 22-, 21-, or 19-G). e size of the
needle may aect the quantity of tissue obtained, degree
of tissue trauma, amount of aspirated blood (which can
aect the quality of the specimen), diagnostic yield,
and maximal angulation range of the EBUS bronchoscope (Fig. 2.1). e increasing number of EBUSTBNA needles has prompted several investigations
on their comparative diagnostic performance. e
most common needles are 22-G and 21-G needles;
however, there are little data supporting the use of one
over another for its size. A large cohort of 1299 patients
showed no dierences in the diagnostic yield of 22-G and
21-G needles for the diagnosis and staging of NSCLC.
59
Adequate samples were obtained in 94.9% of the 22-G
needle group and in 94.6% of the 21-G needle group
(P = 0.81). A pathologic diagnosis was obtained in
51.4% of the 22-G group and 51.3% of the 21-G group
(P = 0.98). ese results suggest there is little dierence
when selecting between 22-G and 21-G needles for
cytologic evaluation via TBNA.
19-G EBUS-TBNA Needle
e 19-G EBUS-TBNA needle is considered a histology needle, with the hypothesis that obtaining a core
biopsy could improve diagnostic yield. Kinoshita et al.
retrospectively evaluated two prototype 19-G EBUS-
60
TBNA needles.
In this study, including 82 target
lesions (72 lymph nodes and 10 lung tumors) in 45
patients, the authors found the pooled diagnostic yield
of the 19-G EBUS-TBNA needles was 100%, with 28%
of specimens being sucient for histopathologic diagnosis. Recently, an EBUS-TBNA-specic 19-G needle (NA-U402SX-4019; Olympus, Tokyo, Japan) has
become commercially available. is needle has a exible tip segment that better preserves scope angulation
61
while maintaining a larger inner diameter (0.69 mm vs.
A B C D E F
Fig. 2.1 Flexibility of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) needles and max-
imal up-angulation of an EBUS bronchoscope (BF-UC180F, Olympus, Tokyo, Japan). (A) BF-UC180F without a needle.
(B) ViziShot2 FLEX 19-G needle (Olympus Surgical Technologies America, Westborough, MA, USA). (C) ViziShot 22-G
needle (Olympus, Tokyo, Japan). (D) ViziShot2 25-G needle (Olympus, Tokyo, Japan). (E) Expect Pulmonary 25-G needle
(Boston Scientic, Marlborough, MA, USA). (F) EchoTip ProCore HD 25-G (Cook Medical, Bloomington, IN, USA).
CHAPTER 2 Linear Endobronchial Ultrasound
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62
0.41 mm with 22-G needles).
Several studies have since
reported on the performance of this commercial 19-G
needle (Table 2.1). Doom et al. demonstrated excellent
diagnostic yield (39/39 100%) that was identical to using
a 21-G needle (39/39 100%) in a randomized control
62
In this study, they found that the 19-G tissue spec-
trial.
imens were bloodier and had a larger tissue surface area
than 21-G specimens. Another prospective randomized
trial including 107 patients similarly found that 19-G
samples contained signicantly more tissue than 21-G
63
samples (20.0 vs. 10.2 mg, P = 0.0119).
However, the
larger needle size was once again associated with signicantly bloodier samples (P = 0.029). e diagnostic yields were similar with both needles. ese results
suggest that, given the already excellent performance
of cytologic 22- and 21-G needles, the added benet of
19-G needles is not related to improved diagnostic yield.
Rather, the reliable acquisition of greater tissue volumes
11
may facilitate use of multiple molecular (e.g., NGS) and
pathologic tests (e.g., programmed death-ligand 1 [PDL1] staining). Further investigation is needed to evaluate
such use.
25-G EBUS-TBNA Needle
Currently, three types of 25-G EBUS-TBNA needles are
commercially available: the EchoTip ProCore HD (Cook
Medical, Bloomington, IN, USA), the Expect Pulmonary
needle (Boston Scientic, Watertown, MA, USA), and
the ViziShot2 (Olympus, Tokyo, Japan) (Fig. 2.2). e
underlying justication for the development of these
needles was to reduce injury to biopsied nodal and
lung tissue, as well as reduce contamination. However,
only a limited number of studies have been published
(Table 2.2). A retrospective study by Di Felice et al.
evaluated 158 lymph nodes, nding that 25-G and 22-G
needles achieved comparable specimen adequacy (P = 1)
TABLE 2.1 Studies on the Diagnostic Performance of 19-G Needles
Reference Year Study Design Number
Pickering
64
et al.
Dooms
62
et al.
Tremblay
65
et al.
Jones
66
et al.
Balwan
67
et al.
Garrison
68
et al.
Minami
69
et al.
Chaddha
70
et al.
Tyan
61
et al.
Gnass
71
et al.
Trisolini
53
et al.
2019 Prospective
2018 Randomized
2018 Retrospective 154 119/154
2018 Retrospective 100 96/100
2018 Retrospective 15 14/15 (93%) N/A
2018 Retrospective 48 45/48 (94%) N/A
2018 Retrospective 11 9/11 (81%) N/A
2017 Prospective
2017 Retrospective 47 42/47 (89%) 24/27 (89%) 18/20 (90%) One moderate
2017 Retrospective 22 22/22
2017 Retrospective 13 13/13
Pooled diagnostic yield
a
N/A, not assessed
observational
control trial
observational
47 16/47 (97%) N/A
39 39/39
56 lymph
nodes
n = 552
Overall
Diagnostic
Yield
(100%)
(77%)
(96%)
52/56 (93%) N/A
(100%)
(100%)
84.6%
Diagnostic
Yield for
Malignancy
a
32/32
(100%)
a
N/A
a
N/A
a
a
a
a
15/15 (100%) 7/7 (100%) None
12/12 (100%) 1/1 (100%) One mild
Diagnostic
Yield for
Nonmalignancy Complication
a
N/A
None
7/7 (100%) None
a
N/A
One moderate
bleeding
a
N/A
None
14/15 (93%) None
a
N/A
N/A
N/A
a
a
None
None
None
bleeding
bleeding
12
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SECTION 1 Advanced Diagnostic Bronchoscopy Procedures
A B
Fig. 2.2 Comparison of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) needles. (A)
From top to bottom, the Expect Pulmonary 25-G needle (Boston Scientic, Marlborough, MA, USA), EchoTip ProCore
HD 25-G (Cook Medical, Bloomington, IN, USA), and ViziShot2 25-G needle (Olympus, Tokyo, Japan) are shown.
(B) From top to bottom, Expect Pulmonary 25-G needle (Boston Scientic, Marlborough, MA, USA), the EchoTip
ProCore HD 25-G (Cook Medical, Bloomington, IN, USA), ViziShot2 25-G needle (Olympus, Tokyo Japan), ViziShot
22-G needle (Olympus, Tokyo, Japan), and the ViziShot2 FLEX 19-G needle (Olympus Surgical Technologies America,
Westborough, MA, USA).
TABLE 2.2 Studies and Cases of 25-G Needles
Reference Year Study Design Number Diagnostic Yield Complication
Di Felice et al.
Matsumoto et al.
Okubo et al.
Waheed et al.
a
N/A, not assessed
with similar diagnostic accuracy (P = 0.7); the sensitivity, specicity, NPV, and diagnostic accuracy of the
25-G needle were 88.9% (95% CI, 51.8%–99.7%), 100%
(95% CI, 92.1%–100%), 97.8% (95% CI, 87.6%–99.7%),
and 98.2% (95% CI, 90.1%–100%), respectively.
comparison, the sensitivity, specicity, NPV, and diagnostic accuracy in the 22-G group were 77.8% (95% CI,
40%–97.2%), 100% (95% CI, 86.8%–100%), 92.9% (95%
CI, 79.3%–97.8%), and 94.3% (95% CI, 80.8%–99.3%),
respectively. Another retrospective study also found
similar diagnostic accuracy with 25-G (100%, 25/25)
and 22-G (90.7%, 68/75) needles.
tively evaluated 104 patients, nding that 25-G needles
72
73
74
75
2018 Retrospective 79 73/79 (92%) None
2017 Retrospective 29 29/29 (100%) N/
2017 Case report 1 1/1 (100%) None
2017 Case report 1 1/1 (100%) None
a
provided adequate samples for NGS as frequently as
48
22-G needle samples.
Further study evaluating more
detailed features of the 25-G needle and biopsy samples
is needed.
72
By
Therapeutic Endobronchial Ultrasound-Guided
Transbronchial Needle Injection
Transbronchial needle injection (TBNI) via conventional bronchoscope has been previously used to
administer various therapeutic agents for the treatment
76
73
Stoy et al. retrospec-
of bronchial malignancies or stulas.
is a relatively new technique that has been described
for the treatment of recurrent NSCLC.
EBUS-TBNI
77
Mehta et al.
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13
described cisplatin injection into a total of 41 sites
78
in 36 patients by EBUS-TBNI.
Complete or partial
response was observed in 69% (24/35) and median
survival for the group was 8 months (95% CI, 6–11
months). EBUS-TBNI may potentially have utility for
benign conditions as well, though data are also limited
to case reports. Parikh et al. described a 71-year-old
female with an aspergilloma who received intralesional amphotericin B (total dose 175mg; 2.5 mg/kg)
by EBUS-TBNI.
79
S U M M A RY
EBUS-TBNA via linear EBUS brought about a paradigm
shi in nodal staging in lung cancer. e use of EBUSTBNA has since expanded to include tissue acquisition
for the diagnosis of a growing number of intrathoracic
diseases and biomarker testing for precision medicine.
More recently, the potential utility of linear EBUS as a
therapeutic modality (via TBNI) has received growing
attention. Its broad indications and low complication
rate make EBUS a vital technical skill for physicians specializing in interventional pulmonary procedures.
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